Fregon, Gail . , tit i'e)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
>< Name First Middle Last Sex
Gail Lee Fregon Female
3 Date of Death Age If Veteran of U.S. Armed Forces,
.i 1 1 /4/201 8 61 yrs. War or Dates 1 981 -1 997
Place of Death Town of Hospital, Institution or
U. City, Town or Village Ticonderoga Street Address 757 Shore Airport Road
2 Manner of Death Jj Natural Cause 0 Accident El Homicide 0 Suicide 0 Undetermined n Pending
C. Circumstances Investigation
W Medical Certifier Name Title
C Tricia Miller P.A.
iip Address
2679 Main Street, Crown Point, NY 12928
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 39
❑Burial Date Cemetery or Crematory
11 /07/2018 Pine View Crematory
❑Entombment Address
><.®Cremation Oueensbury, New York
Date Place Removed
❑Removal and/or Held
l and/or Address
w Hold
Date Point of
Q Transportation Shipment
by Common Destination -
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
M. Permit Issued to Registration Number
W. Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, New York 12883
W. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
In
Permission is hereby granted to dispose of the human re ins scribed ove'as ndicated.
i:if
<< Date Issued 11 /7/2 01 8 Registrar of Vital Statistics r' '4 ii` y4.,,,
j ( gnature)
District Number 1 564 Place Town of Ti co deroga
'`' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ut Date of Disposition 0O$II g Place of Disposition ,,U.,., j�1-0...,
(address)
.11
VI
IP (section) / (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises 1�r9 �, ,�j,�.'
', please print)
Signature 41,
Title lic�
(over)
DOH-1555 (02/2004)